1. CC: chest pain for 2 hours
HPI：62 yo female with PMH significant for HTN, hypercholesterolemia presented
with chest pain for past 2 hours. Pt reported that after dinner while she was
watching TV the pain started. Pain started with chest discomfort initially but has
gotten more intense over the past 2 hours. Pt described that pain is tight and heavy
feeling, not related to body position, located in substernal area, radiate to whole
chest area, but more obvious in left chest up to jaw area. No associated symptoms,
but has felt some palpitation with mild shortness of breath. Not sure what makes
pain better or worse but felt that she was not able to walk fast due to chest
discomfort and SOB. Pt does not recall any similar chest pain in the past prior to 3
weeks ago. No recent ECHO or stress test. Pt has felt some chest tightness with
shortness of breath while climbing 2 flights of stairs in the past 3 weeks, relieved
with rest. No recent travel. Pt usually does walking daily for 30min without any
problem. No cough, fever, pleuritic chest pain or rash noted. Has GERD like
symptoms occasionally, but reported GERD symptoms were burning chest pain.
PMH: GERD, HTN, hypercholesterol, fatty liver, asthma
MED: ant-acid, diovan, norvasc, Lipitor, b-agonist inhaler prn. (pt can’t give full
medication name, but does know that she has med for GERD, high chol and BP with
inhaler).
Allergy: NKDA
Shx: widowed for 3 years, live with son and daughter in law. No smoking, no
drinking. No recent travel, no IVDU.
Fhx: father has HTN, CAD, died of car accident at age 68. Mom has HTN, DM, died
of DM complication.